don’t vacillate, ventilate-ventilate-jud.pdffailure of extubation • the decision to ventilate...

DON’T VACILLATE, VENTILATE

DR JUDITH KILLEN

WAGGA WAGGA RURAL REFERRAL HOSPITAL

DON’T VACILLATE, VENTILATE

DR JUDITH KILLEN

WAGGA WAGGA RURAL REFERRAL HOSPITAL

WHY WE HAVE INTENSIVE CARE

• Intensive nursing care

• Advanced ventilatory monitoring & support

• Advanced haemodynamic monitoring and support

• Emergency renal dialysis & haemofiltration

FAILURE OF EXTUBATION

• The decision to ventilate can be thought of as a prediction of failure of extubation

• We have expanding data bases of the size of the issue from closed claim sources, studies such as NAP4, and maternal mortality analyses

AWAKE, BREATHING, PAIN FREE

GENERAL PREOPERATIVE ASSESSMENT

• Nutrition (albumin, urea, white cell count red cell morphology)

• Pre-existing disease – COPD, CCF, liver failure, neurological disease

• Age

• Obesity, OSA

DOES THE PATIENT CONSENT TO POST OPERATIVE VENTILATION?

• Hard to ask once the patient is anaesthetised.

• May not be possible to ask

• Ask about existing forward directives

• Involve family if possible

FORWARD DIRECTIVE

IS THE UPPER AIRWAY PATENT?

• Allergy

• Infection – bacterial or viral eg epiglottitis, croup, quinsy

• Burns – thermal or chemical

• Neoplasm

• Trauma including spinal cord injury

• Swelling associated with the surgical procedure

STARTING FROM THE TOP

AN OBSTRUCTED UPPER AIRWAY

PRE EXISTING UPPER AIRWAY ISSUES

• Obesity

• Obstructive sleep apnoea

• Abnormal anatomy (treacher collins etc)

• Radiotherapy

• Rheumatoid

RADIATION THERAPY

THE GLOTTIS

• Laryngospasm

• Vocal cord paralysis

• Extrinsic compression

VOCAL CORD PARALYSIS

IS THE PATIENT ABLE TO PROTECT THEIR AIRWAY?

• Vocal cord paralysis

• Cough strength

• Secretions

• Bleeding

• Residual paralysis

HAEMATOMA ANTERIOR TO CERVICAL SPINE

CHEST TRAUMA

• Rib fractures

• Pneumothorax

• Haemothorax

• Lung contusion

CHEST WALL INTEGRITY

LUNG INTEGRITY

• Chronic lung disease

• Heart failure

• Infection

• Trauma

COPD / CCF

EMPHYSEMA

BAD COMBINATIONS

• Inadequate respiratory function and thoracic or subdiaphragmatic surgery

• Neck brace plus laparotomy

• Neurological disease plus surgery

IDENTIFIED RISK FACTORS FOR FAILED EXTUBATION

• Age

• Frailty

• Obesity

• OSA

• Delerium

• Haemodynamic instability

• CCF

?AN INCREASING OR DECREASING PROBLEM

EVACUATION

• Children

• Burns

• Spinal Injuries

• For treatments unavailable in your institution such as ECMO

NOT SUITABLE FOR REGIONAL ICU!

PACKAGE YOUR PATIENT

• It may be easier to put lines in in the OR

• What lines are needed?

THANKYOU! & GOODLUCK!